Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
When is air travel safe for patients who have developed an intracranial bleed?
I tried to find evidence-based guidance from the literature, but I found only a few pieces of advice. After ICH, unless it was tiny and of clear cause, I would wait at least 4-6 weeks. After SDH, if neurosurgical drainage was performed, then also at least 6 weeks. After SAH, assuming the causative a...
When do you start anticoagulation in patients with endocarditis and evidence of mycotic aneursym?
True estimates of the risk of anticoagulation in endocarditis is hard to come by, since anticoagulation is not common in practice and likely the risk is dynamic and decreases with antibiotic treatment. If one considers thrombolysis as a guide, the presence of endocarditis appears to increase the ris...
How does lack of success of rituximab treatment affect your decision to trial anti-CD19 therapies like inebilizumab?
I strongly believe that deeper and broader CD19 theraphy such as inebilizumab, works on a key different target: offering better disease control due to its broader B-cell targeting, as in CD19, plasmablasts, than rituximab, which targets CD20 (mature B cells), leading to more broad b cell depletion,...
How do you differentiate between HIV associated neurocognitive disease (HAND) and other causes of neurocognitive impairment?
This is a great question. In the era of test and treat, where many people with HIV have never had significant immunocompromise, cognitive impairment due to HIV itself is now relatively rare. On the other hand, people with HIV experience conditions of aging about 10 years earlier than people without ...
What are the best practices for centers interested in providing anti-amyloid therapies for early Alzheimer's to ensure treatment delivery success?
I would use the same criteria for AAA treatment as those required for entering AAA clinical trials. Overall, our center has not had difficulty with ensuring that patients have timely MRIs before treatments. I enlist caregivers and patients to remind me when they are scheduled for their next infusion...
When do you consider hemispherectomy for patients with Rasmussen encephalitis with stable epilepsy and preserved function of the affected half of body?
Depends on several factors. First, how debilitating are the seizures? If the person cannot function, like going to school for children or adult activities, then surgery to stop the seizures should be considered. Also, age is a factor. Children under the age of 5 years should be considered to make us...
Which clinical or imaging features of cerebral amyloid angiopathy aid in predicting future risk of intracerebral hemorrhage?
Hemorrhagic imaging features of cerebral amyloid angiopathy can help understand the future risk of intracerebral hemorrhage (ICH). Observational studies have found that patients with cortical microbleeds without lobar hemorrhage have an ~5% risk of future ICH. In those with prior lobar ICH, this ris...
What would prompt discontinuing treatment versus switching or sequencing treatment in patients treated with an anti-amyloid therapy for Alzheimer's?
To be sure, there is virtually no evidence of outcomes on switching from one antibody to another. If treatment discontinuation occurred due to ARIA, I would strongly discourage rechallenge with another agent. There is no rationale for discontinuing lecanemab or donanemab for lack of efficacy on clin...
When do you recommend neuropsychiatric testing in patients with post-concussive syndrome?
I typically ask the patient what scenarios they experience cognitive issues. The various examples they provide usually relate to difficulty following conversations, forgetfulness within their working memory, and concentration/focus. In the post-concussion patient, they typically have developed adjus...
How are you using CYP2C19 genotyping for determining dual antiplatelet therapy for stroke?
In my practice, P2Y12 assays are the primary tool I rely on for guiding dual antiplatelet decisions. They are more widely available across clinical settings, whereas CYP2C19 genotyping requires infrastructure that is not always accessible outside of large academic and tertiary centers. CYP2C19 ident...